Shingles Vaccine Age Recommendation
The recombinant zoster vaccine (RZV/Shingrix) is recommended for all adults aged ≥50 years, with RZV strongly preferred over the older live-attenuated vaccine (ZVL/Zostavax). 1
Standard Age Recommendation for Immunocompetent Adults
- RZV is recommended starting at age 50 years for all immunocompetent adults, regardless of prior herpes zoster history or previous Zostavax vaccination 1, 2
- The vaccine is administered as a 2-dose series with the second dose given 2-6 months after the first dose 1, 2
- No upper age limit exists for vaccination; the vaccine maintains high efficacy across all age groups ≥50 years 1
Expanded Indication for Immunocompromised Adults
- For immunocompromised adults, RZV is recommended starting at age ≥18 years if they are or will be at increased risk for herpes zoster due to immunodeficiency or immunosuppressive therapy 1, 3
- This includes patients with solid cancers, hematologic malignancies, autoimmune conditions, or those receiving immunosuppressive medications 1
- For immunocompromised patients, a shorter dosing schedule may be used with the second dose given 1-2 months after the first dose 1, 2
Rationale for Age 50 Years Threshold
The age 50 recommendation is based on robust clinical trial data demonstrating exceptional efficacy:
- RZV demonstrated 97.2% vaccine efficacy in preventing herpes zoster in adults aged ≥50 years in the pivotal ZOE-50 trial 1, 4
- Efficacy remains consistently high across all age subgroups, with 89.8% efficacy in adults ≥70 years in the ZOE-70 trial 1
- Protection against postherpetic neuralgia (PHN) reaches 88.8% in adults ≥70 years 1
- Vaccine protection persists above 83.3% for at least 8 years, with minimal waning to approximately 73% at 10 years 1, 2, 4
Why RZV is Strongly Preferred Over Zostavax
RZV represents a substantial improvement over the older live-attenuated vaccine:
- Zostavax efficacy was only 51.3% in adults aged ≥60 years and declined dramatically with age (70% at ages 50-59 years vs. only 18% at age ≥80 years) 1, 4
- Zostavax protection wanes significantly over time, dropping to only 14.1% efficacy by year 10 2, 4
- RZV can be safely administered to immunocompromised patients, while Zostavax is contraindicated in this population 1, 3
- Network meta-analysis confirmed RZV is significantly more effective than Zostavax in preventing both herpes zoster and PHN 1
Important Clinical Considerations
Previous Zostavax Recipients
- Adults who previously received Zostavax should still receive RZV, with a minimum 2-month interval after the last Zostavax dose 1, 2
- This recommendation exists because Zostavax provides inadequate long-term protection 2
After Herpes Zoster Episode
- Vaccination is recommended even after a shingles outbreak, with a minimum 2-month waiting period after acute symptoms resolve 1, 2
- Prior herpes zoster does not provide reliable protection against recurrence (10.3% cumulative recurrence risk at 10 years) 2
Common Pitfalls to Avoid
- Do not screen for varicella history or perform serologic testing before vaccinating immunocompetent adults aged ≥50 years 1
- Do not delay vaccination in adults aged ≥50 years who lack documented varicella history; proceed with RZV vaccination 1
- For known VZV-seronegative individuals, administer 2 doses of varicella vaccine (4 weeks apart) rather than RZV 1
Safety Profile
- Grade 3 injection-site reactions occur in 9.5% of recipients (vs. 0.4% with placebo) 1, 2
- Systemic symptoms occur in 11.4% of recipients (vs. 2.4% with placebo) 1, 2
- No difference exists in serious adverse events or deaths between RZV and placebo groups 1
- Most adverse reactions are transient and mild-to-moderate in severity 5